A Virginia insurer overturned their decision to deny reimbursement for 6 outpatient sessions, originally not deemed medically necessary. Recently, the Maryland Parity Project assisted a Maryland psychologist file an appeal in an attempt to secure reimbursement for 6 outpatient sessions that took place in 2011. The insurer in the case denied authorization for the sessions, claiming prior authorization was needed and not obtained.
The psychologist had attempted to appeal the adverse decision in February of 2012, but the insurer did not respond to this request. MPP filed the appeal based on the requirement that the insurer must inform the member and provider of the appeal rights and must respond to all appeal requests in writing- as this was not done, the clock never started ticking on the appeal deadline. In the appeal filing, MPP also requested the insurer to provide documentation showing their prior authorization processes and medical necessity criteria met the “comparable and no more stringently” standard of the federal mental health parity law. The insurer declined to do this but did overturn their decision and approved the six visits.
MPP will stay engaged in the case to ensure the psychologist is fully reimbursed for the outpatient sessions and to file any potential parity complaints against this plan.
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